Healthcare Part 2

Peru seems to be making a really concerted effort to grapple with the large health issues that face their citizenry. One way is to provide healthcare coordinated through community clinics. The other morning we took a tour of one of them. The center serves a community of 33,000 people. It is one of about 10 other satellites in one of the regions in Lima. It in turn supports 10 smaller satellites. Their mission is to provide routine medical services (including obstetrics with 150 deliveries/month), emergency care, and education for the local citizenry. It is in a poor working class community surrounded by squatter’s homes on a hill, smaller in magnitude but similar, I would guess, to the favelas in Rio. As Peru’s prosperity has burgeoned modestly over the past decade, this community has as well.

The centers have targeted pregnant mothers, infant and child health, Tbc, HIV/AIDS, population control and sexually transmitted diseases. The clinic is the hub for providing public health information and support as well as prevention and treatment for common and important problems. Their approach to Tbc provides a good insight into how they work. If you read Mountains Beyond Mountains you know that Peru has had problems with Tbc, and especially the multi-drug resistant variety (MDRTB – multiple-drug resistance Tbc). Patients with high risk symptoms (e.g., persistent productive cough, fever, weight loss) are encouraged to go for an evaluation. Family members can ask for advice and clinic staff will make home visits. Once identified, Tbc patients are placed in a Direct Observation Treatment, short course (DOTS) program (http://www.who.int/tb/dots/whatisdots/en/index.html). This includes being placed on a database where information about attendance at the clinic is recorded. When they miss there is prompt follow-up. Scrupulous adherence to a medication regimen is essential for cure as well so to minimize the possibility MDRTB. HIV/AIDS and Tbc are bad for each other so all Tbc patients are tested for HIV; all HIV patients are screened and monitored for Tbc. Anyone testing positive for HIV is treated, the medications supplied by the clinic for free. They also check all family members including skin testing (PPD).  When appropriate, preventive and/or treatment medications are provided, too.  Children are particularly vulnerable to developing Tbc with 2 years of contact from someone that they are living with. Tbc in kids can be difficult to diagnose and they suffer with some pretty awful varieties. Kids are very important to Peruvians so they have tried to be proactive. This includes BCG vaccination at birth.  The real question is whether or not this has been effective. Peru has identified as one of the 20+ countries with real problems with Tbc and the emergence of MDRTB. It was one of 2 that has made substantive improvements within the past decade. Still, Tbc is a disease of poverty and poor nutrition. One need not travel far from the comforts of Miraflores to see there are still huge obstacles.

The clinic also screens all pregnant women, sex workers, and people with sexually transmitted infections (STI) for HIV. Birth control advice is offered and a wide range of options (excluding abortions) are available, including tubal ligations and vasectomies, all for free. The clinic also offers sex workers regular checkups, safe sex counselling, and treatment for symptoms of STIs by protocol, all free of charge.  This focus on STIs is important for Peru because unlike the US, HIV is spread here predominately by sex and not IV drug use. In the US there are people who would take great exception to public funds being used in these ways.  Despite the fact that Peru is a Catholic nation and is at least as conservative as the US with regard to sexual matters, many of these efforts thrive under the radar because they are directed toward the poor.

One additional observation. Historically, the spread of Tbc to healthcare workers was low until the late 1940’s. It has been going up since. The changes in hospitals over the past 60 years have no doubt contributed. Rather than open windows, modern hospitals now rely on closed ventilation systems. These systems are no match for the breezes that used to sweep in and through a hospital wing’s worth of windows. Ultraviolet (UV) light (aka sunlight), the bane of existence for Tbc, is in short supply in buildings with roofs, long hallways and few windows. Given that Tbc is spread by droplets, it should come as no surprise that resistant strains spread when people with TBC come into close contact, especially before their treatment has started taking effect. It would seem that bringing infected people together at clinics for DOTS would be a disaster waiting to happen. The solution? At least in the clinic we visited, Tbc patients wait outside on benches in a patio, bathed (at least metaphorically) by sunlight and a breeze rather than in a closed, cramped waiting room. This is not a great solution for Siberia but it makes sense here and in tropical and subtropical climates generally.

The clinic and its surroundings were clean and the patients and staff seemed positive and enthusiastic. Although this was prearranged, I don’t believe that we were just given a photo op. Quite frankly, their efforts embarrass me as an American when I think about what we do and do not do with our resources.  We have a president with a majority in both houses and still they squabble with special interests while the really important discussions about the fundamental issues of healthcare queue up behind what seems like a lot of nonsense.  Peruvians, with limited funds, have decided do something by addressing the problems that they perceive will have the biggest long term impact on the future of the country.  They have had to make difficult decisions, limited by resources.  In some cases, these decisions have resulted in interesting innovations.  Microscopic-observation direct susceptibilities (MODS), invented in  Peru, provides a faster and cheaper way to grow Tbc in culture and determine drug susceptibilities. 

No one knows if these are the right problems or solutions but Peruvians are trying and they seem to be making headway.  Many of the instructional staff here at Gorgas are seriously involved in the dialogue.  I am proud to be associated with them.

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